Provider Demographics
NPI:1992197107
Name:PROM, CHANTRA (PHARMD)
Entity type:Individual
Prefix:
First Name:CHANTRA
Middle Name:
Last Name:PROM
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7940 PENN AVE S
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:MN
Mailing Address - Zip Code:55431-1315
Mailing Address - Country:US
Mailing Address - Phone:952-252-1154
Mailing Address - Fax:952-252-1157
Practice Address - Street 1:7940 PENN AVE S
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:MN
Practice Address - Zip Code:55431-1315
Practice Address - Country:US
Practice Address - Phone:952-252-1154
Practice Address - Fax:952-252-1157
Is Sole Proprietor?:Yes
Enumeration Date:2015-02-25
Last Update Date:2015-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN121468183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist